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APPLICATION FOR PERMIT !rr«! F SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE® Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '.R G 8 1990 (Complete in Triplicate) SAN JOAQWN Cf. UMTY PUBLIC HEAL i I-I SERI .1;;ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install 1hf_NV1R0RWl4T4W1"VkL11 MI"W is made in compliance with San,'Jo3quin County Ordinance No.•549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1601 Edna Court L City Tracy Lot Size 2301 x2621 PM owner's Name G.E. Whitlock Const.. Address 1131 Marian Ct_ , Trar-y Phone 83 - Contractor Hennings_ Bros. Address 3525 Pel andale, Modesto icense No.290813._._,.__. Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL CT( WELL REPLACEMENT L DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 100, SEWER LINES DISPOSAL FLD.-.100'_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1— Dia. of Well Casing 611 iX Domestic I Private EX Gravel Pack X Tracy Type of Casing DVS VC Specifications FI Public Ll Other Delta Depth of Grout Seal 1001 Type of Grout Bentonite I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by driller _ Repair Work Done D Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION I 1 INo septic system permitted if public sewer is 6 available within 200 feet.) Installation will serve: Residence— Commercial.= Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.. ❑ A Method,of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size (� FILTER BED ❑ Distance to nearest: Well Foundation Property Line `y�• SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well _ _ Foundation _ Property Line_ DISPOSAL PONDS ❑" I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing averse sidi. Signed x He�ingsBros. _ By Title Date: 3-7-90 FOR DEP T T USE ONLY �� Application Accepted by Date Q1�/ Area. 16 -, Pit or Grout Inspection b r Date Final Inspection by 4a Date Additional Comments: ��–l�0 ` ��ft Y /dv � /Zrw� ❑ Stk 466-6781 ❑ Lodi 369-3621 /El Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S121 — /`/v f u-�r !Sia 6 r A. FEE INFO AMOUNT ❑UE AMOUNT REMITTER C H RECEIVED 6Y DATE PERMIT'NO. + EH 1324 fREV.r/H5) EH 14-29 or 4Z) p fl